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BRIOVARX OF MASSACHUSETTS, LLC
DSH330214 NYU Langone Hospitals
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Covered Entity Details
Entity Name
NYU Langone Hospitals
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330214
Entity Address
550 FIRST AVENUE
NEW YORK, NY 10016
Medicare Provider Number
330214
Participating Start Date
1/1/2016
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
BRIOVARX OF MASSACHUSETTS, LLC
Pharmacy Address
D/B/A BRIOVARX
BLDG 2 - UNIT A
145 BODWELL STREET
AVON, MA 02322
Pharmacy Comments
Contract Details
Approval Date
1/18/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/12/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Burke, Corporate Chief Financial Officer
(212) 263-3092
Contract Pharmacy Representative
Optum
NATHAN WHITE, Vice President Sales - TPA & Hospital
(813) 949-1951
Signed By Date
1/18/2017
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